ANA OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.

Find Out More...

Letter to the Editor

  • A critical element of preparing competent nursing students, not mentioned in "Crisis in Competency: A Defining Moment in Nursing Education", is the need to eliminate barriers to recruiting and retaining nurse educators still engaging in clinical practice.

  • Continue Reading...
    View all Letters...

The Complex Work of RNs: Implications for Healthy Work Environments

m Bookmark and Share

Patricia R. Ebright, RN, DNS, CNS


This article describes the complex work of registered nurses (RNs) in current healthcare settings and presents strategies for promoting healthy work environments in the midst of this complexity. First it addresses the complexity in delivering patient care by reviewing recent research on the work of nursing and explaining the concept of RN stacking. Then it considers four important activities for supporting RN decision making and establishing a healthy work environment, namely, “designing out” system barriers to care, designing and implementing appropriate technology, focusing on nursing direct care functions, and supporting the new RN.

Citation: Ebright, P., (Jan. 31, 2010) "The Complex Work of RNs: Implications for Healthy Work Environments" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol15No01Man04

Keywords: cognitive work of nursing, complex adaptive system, complexity science, complex work environments, mindfulness, patient care assignments, prioritizing, RN stacking, RN work complexity, situation awareness, stacking, trade-off decisions, workflow management

The complexity of nursing work has received increased attention since the Institute of Medicine (IOM) issued its report on medical errors in 2000. Healthcare providers and administrators are now focusing efforts on learning how industries other than healthcare deal with operation breakdowns and catastrophic failures related to errors, and how they increase the reliability of their processes to promote safety and quality (Weick & Sutcliffe, 2007). Research addressing the work of nursing has identified the marked complexity surrounding the delivery of care in our current healthcare environments, and has begun to understand why intended outcomes are often not achieved, even with excellent education programs and redesigned healthcare systems.

Understanding the complexity of delivering nursing care is essential for making changes that effectively promote...healthy work environments... Understanding the complexity (difficulty) of delivering nursing care is essential for making changes that effectively promote the healthy work environments advocated by the American Association of Critical Care Nurses (AACN, 2005). This article presents new understandings about the complex cognitive work (organizing, prioritizing, and making decisions) of nursing. This cognitive work, called “stacking,” has many implications for the development of healthy work environments. To achieve the intended outcomes of healthy work environments, namely quality care, safe patient outcomes, and nurse recruitment and retention, it is necessary to direct attention to the invisible, cognitive work of nurses, i.e., work that promotes suitable work flow and care delivery, and to factors that support or complicate this invisible work. Failure to understand how registered nurses (RNs) make decisions in the context of actual care delivery will lead to the design of processes, environments, and technologies that increase the complexity of RN cognitive work. This failure in turn will lead to increased RN stress and dissatisfaction, decreased RN retention, and ultimately unsafe care.

First, I will present the latest research findings describing the complexity of nursing decision making involved in the delivery of care. Next I will describe the implications of these research findings for promoting healthy work environments and the intended goals of quality care, safe patient outcomes, and nurse retention and recruitment. In conclusion I will address four important activities that will support the decision-making work of nurses, namely, (a) “designing out” system barriers to care, (b) designing and implementing technology, (c) focusing on the direct care function, and (d) supporting the new RN.

The Complexity in Delivering Care

This section will describe the complexity of delivering patient care. First it will present recent research on the work of nursing. Then it will discuss the concept and implications of a phenomenon called ‘stacking.’

Recent Research on Nursing Work

Recent research regarding the difficulty of delivering nursing care has resulted in a shift in thinking for nurse educators and healthcare administrators as to best ways for improving quality, promoting patient safety, and retaining staff nurses. New insights about the importance of focusing on systems have prompted some nursing administrators, educators, and researchers to pay more attention to how nursing care can be delivered successfully in even the most difficult of situations. Researchers are now investigating what went wrong in the system when care was not delivered as intended. Their attention has turned from strategies focusing on individual nurse remediation or textbook education to focusing on the care-delivery system.

In 2003, researchers provided a description of RN work patterns across medical-surgical units. Specifically, the researchers identified factors that make the work of nursing care very challenging. These factors included missing equipment and supplies, interruptions, waiting for needed resources, communication inconsistencies, and lack of time (Ebright, Patterson, Chalko, & Render, 2003). Other researchers (Kalisch, 2006; Krichbaum, et al., 2007; Potter et al., 2005; Tucker & Spear, 2006) have reported additional factors that challenge nurses while delivering care. Potter et al. noted that nurses make frequent cognitive shifts, deal with many interruptions, and develop a cognitive load having the potential for disrupting attention, all in the midst of providing care. Through direct observation, interviews, and surveys, Tucker and Spear identified a number of major categories of obstacles to nursing care, including physician orders, obtaining equipment and supplies, and staffing. These researchers reported that the average time nurses in this study spent at one task was 3.1 seconds and that nurses were interrupted mid-task eight times per shift.

Kalisch (2006) reported nine different activities that were sometimes missed by nurses, namely ambulation, turning, delayed or missed feedings, patient education, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance. RNs shared with Kalisch the following reasons for missed care: too few staff, time required for a nursing intervention, poor use of existing resources, “not my job” syndrome, ineffective delegation, habit, and denial. Krichbaum et al. (2007) identified a nurse care-delivery experience they termed ‘complexity compression,’ and noted this experience occurs when nurses are expected to assume, in a condensed time frame, additional, unplanned responsibilities while simultaneously conducting their other multiple responsibilities. Nurses reported that personal, environmental, practice, administrative, system and technology factors, as well as autonomy and control factors, all contributed to this experience.

Nurses use knowledge over and above that related to pathophysiology, pharmacology, specific nursing diagnoses, medical diagnoses, and possible interventions to inform their decision making about what patient care to deliver (Ebright et al., 2003; Ebright, Urden, Patterson, Chalko, 2004). Nurses also use knowledge about unit norms, current resource availability, relationships with co-workers, and system processes in making patient-care decisions. All these types of knowledge, as well as nurses’ knowledge about the moment-to-moment status of their patients, are used to inform their decision making regarding how and when to deliver care (Ebright et al., 2003). Ebright and colleagues have identified specific strategies RNs use to deal with the factors that make their work difficult. These strategies include thinking ahead and acting proactively, strategic delegation, and use of hand-written notes for remembering and tracking care (to-do lists), as well as the cognitive process of continuously organizing, re-prioritizing, and making decisions for the management of workflow and care delivery. Researchers call this process “stacking.”

RN Stacking

Stacking is the invisible, decision-making work of RNs about the what, how, and when of delivering nursing care to an assigned group of patients. Stacking is the invisible, decision-making work of RNs about the what, how, and when of delivering nursing care to an assigned group of patients (Ebright et al., 2003). This process results in decisions about what care is needed, what care is possible, and when and how to deliver this care. For example, as nurses arrive on their units at the beginning of a shift, they already have a mental list of the tasks/activities that will direct their first work-related behavior. It may be to find out about their patient assignment (number of patients, diagnoses, location of patients on the unit); unit-related duties, such as orienting a new RN or working with a student; and seeing who is working that day. Information from each of those observations will inform the order of care and unit-related activities in their list of to-do’s. What follows with each new observation and receipt of information from minute to minute is a continuous re-ordering of the priorities of the activities in the list. This section will next discuss factors that influence stacking, including stacking ability, non-predictable world views, Complexity Science, trade-offs, and mindfulness.

The ability to stack effectively develops and increases throughout an RN’s experience in actual care-delivery situations which may be far from ideal. Stacking ability. The concept of stacking is not unique to RN work. Some argue that the work of an elementary school teacher or mother caring for toddlers would require continuous re-organizing and priority setting. What is different in each of these work examples, however, is the extent of the knowledge required to make organizing and prioritizing decisions appropriate for the situation encountered and the outcomes desired. Having the knowledge to be a great mother of toddlers would not be sufficient to manage the “stack” of responsibilities faced by an RN providing care to patients. The high degree of clinical judgment, informed by patient and environmental cues, and needed to make decisions that lead to quality care and rescue of patients from complications and potential death, requires sophisticated, RN stacking management of competing priorities. The RN stacking process is continuously informed not only by patient condition and requests, but also by the context of the environment surrounding the nurse and patient, and by unique patient and nurse characteristics. The ability to stack effectively develops and increases throughout an RN’s experience in actual care-delivery situations which may be far from ideal. Stacking becomes a continuous workflow management strategy for nurses as they apply nursing science principles in the actual practice environment. This work is often complicated by the rigid, traditional structure of current healthcare settings.

Non-predictable world view. Traditional healthcare-delivery organizations have been influenced by a ‘predictable worldview,’ i.e., one that assumes that people or units or systems are relatively predictable (Wiggins, 2008). This worldview assumes that in each situation a limited and identifiable number of factors can be understood and predicted. Within this worldview, when events or outcomes do not turn out as intended, the cause is assumed to lie in the factor closest to the problem itself, which in the case of healthcare is the individual caregiver. For example, if the wrong medication is administered by a nurse, a ‘predictable worldview’ response assumes that appropriate checks were not performed resulting in the error. The “fix” to this error is to focus on educating and/or counseling the nurse regarding the appropriate checks. This worldview assumes that if the nurse knows what to check, and does so, this error will not happen again. This predictable worldview seldom takes into consideration the numerous places in the health-delivery system in which this error could have been initiated. In contrast, since the publication of the IOM report (2000), leaders in healthcare are paying relatively more attention to system factors, rather than individual caregiver factors, in order to increase the safety and quality of patient care.

Complexity Science. Using Complexity Science to understand the work of nursing is becoming increasingly accepted as a very fitting approach to explaining healthcare organizational dynamics and the work of nursing (Lindberg, Nash, & Lindberg, 2008). Complexity Science is an interdisciplinary field of research that studies the manner in which complex adaptive systems evolve, interact, and maintain order. A complex adaptive system (CAS) is a system that can adapt to a changing environment. Examples of complex adaptive systems include living organisms (patients), nervous systems, economies, local governments, and corporations. Thus, Complexity Science can be used to explain the complexity of nursing care delivery to one patient (a CAS), within the larger context of an assignment within a unit (another CAS), within a department (an additional CAS), and within a hospital (an even larger CAS). According to Complexity Science each of these CASs, including the patient and nurse, are very dynamic, interconnected, interdependent, adaptive, and diverse. In this view, CASs adapt and change when confronted with real-life situations.

A complex adaptive system is a system that can adapt to a changing environment. The application of Complexity Science principles and CAS properties to nursing care is consistent with the idea of holism (holistic care being an important concept in the science of nursing). Holistic care focuses on the individual, the health of the individual, and the environment, concepts which have always been at the center of nursing science. National nursing scope and standards of practice, such as those developed by the American Nurses Association (2004); nursing education standards, such as those developed by the Commission on Collegiate Nursing Education (n.d.); and individual healthcare facility nursing procedural guidelines all emphasize the importance of a focus on the patient as a unique individual requiring individualized, holistic nursing care.

Viewing healthcare delivery through the lenses of Complexity Science provides a new understanding of the challenges of nursing care delivery within complex systems. A response to the medication error mentioned above using Complexity Science would focus on details surrounding the broader situation in which the nurse was working, and ask the question about why the checks were not able to be completed, if they had not been performed in this situation. A complexity view does not assume that lack of knowledge about checks was the reason for not completing them; rather a complexity view is open to the possibility of multiple contributors to the error.

Trade-offs. In most healthcare settings, whether acute outpatient (emergency), primary outpatient, acute inpatient, procedural, or rehabilitation-focused settings, nurses manage the continuous care and movement of patients. Most staff nurse work includes care of patients as well as work activities related to managing the work environment. This is demonstrated by an intensive care unit (ICU) nurse who has as an assignment one critically ill patient, but who also, as an ICU team member, monitors colleagues and assists or helps with new patient arrivals. Managing both patient care and the work environment is also demonstrated by the endoscopy nurse who performs patient care, monitoring, and physician-delegated activities during a procedure, and who also manages the flow of patients, the readiness and accessibility of records, rooms for the next procedure, and even the moods of other providers in the department. Rarely do the nurses perform one part of their assignment without distraction and/or intrusion of thoughts about what they need to do next in the context of the total shift, patient assignment, or the work of the unit. We have learned that the continuous decision making used to manage very complex situations is influenced by unpredictability, ambiguity, time constraints, inadequate access to resources, lack of control, and often clinical emergencies with potentially catastrophic outcomes (Ebright, Patterson, & Saleem, 2009).

In this context, nursing care-delivery decisions address what is the most important thing to do at a specific moment in a given situation and also what is expected to happen next. RNs provide nursing care in the midst of the continual trade-off decisions they make regarding the most important activity for the moment, how it should be done, and what can wait until later or not be done at all. ‘Trade-off’ decisions are decisions that practitioners make between different but interacting or conflicting goals. These decisions are made in situations of uncertainty, risk, and limited resources (Cook & Woods, 1994).

An example of a situation in which trade-off decisions must be made would be when the RN must decide at a given moment between the following: stay with a patient who is alone, distraught, and anxious about a diagnosis; leave this patient to give a pain medication to a patient who called 15 minutes ago; check on the new graduate nurse who seems to be overwhelmed by her assignment; or prepare a room for a patient returning from the operating room. Each of these individual situations has obvious clinical and/or workflow management implications along with many nuances and details that only the RN in the situation can see. For example, the patient who is distraught and anxious is threatening to refuse treatment and/or testing that is important for his plan of care; the patient who called for pain medication is scheduled for physical therapy and, if not medicated appropriately before the transporter comes, will not get full benefit of the session, and the nurse may be faulted in the weekly pain management audit; the new graduate is caring for patients who are stable but have the potential to ‘crash,’ and the RN wonders whether the new graduate will be able to notice subtle signs of deterioration if overwhelmed by her assignment; and the elderly patient whose surgery was risky and who has multiple co-morbidities is returning from the operating room and will need one-on-one monitoring for several hours.

Mindfulness. Professional nurses’ clinical decision making is influenced by their ability to be mindful of (to pay attention to) and make sense of, changing information within their patient assignment and across their time-limited shift. Most nurses manage clinical and workflow activities successfully, focusing on patient-centered care that is safe and high in quality. The fact that they do not always complete every possible activity that should have, or could have been done is often the result of the best decision making possible, considering the need for trade-off decisions and the complexity involved in the actual situation. Although Kalisch’s research (2006) reported multiple environmental factors that led to missed care, it was not clear how much missed care was due to these environmental factors or forgetting, and how much was due to deliberate decisions resulting from trade-offs between multiple competing clinical and workflow-management tasks.

Stacking revisited. RN stacking is a dynamic, cognitive, decision-making process. Its effectiveness depends on the ability of nurses to be mindful and aware of even subtle changes in their patients, in unit activities, and in the work of other care providers working with them. The ability of nurses to be mindful and to make sense of new information is partly dependent on their previous actual care-delivery experience (Benner, Tanner, & Chesla, 2009). For the new graduate RN, a lack of confidence and/or a lack of experience are deterrents to the mindfulness (ability to pay attention) and clinical reasoning required in complex settings such as healthcare, leading to work-related stress. Yet even nurses who are highly experienced in managing environments that have high levels of unpredictability, ambiguity, and flawed processes are not satisfied with their current work environments (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). It may be that much of the nurse dissatisfaction with work environments is due to the amount of time spent having to make trade-offs between equally important care decisions that affect safety and quality of care.

It may be that much of the nurse dissatisfaction with work environments is due to...time spent having to make trade-offs between equally important care decisions that affect safety and quality of care. RN decision making depends on the ability to notice and make sense of subtle as well as obvious changes. If quality care, safe patient outcomes, and nurse retention and recruitment are the intended goals of creating a healthy work environment, then attention should be directed to RN decision making regarding care delivery and workflow and to factors that support or complicate these aspects of the work. Increasing support for RN decision making (the cognitive work of nursing), or decreasing those factors that complicate nurses’ ability to be mindful and make sense of changes, will result in decisions that lead to safe practice and quality care. In other words, strengthening processes and systems to support RN clinical reasoning, and reducing those factors that get in the way of RN work requiring clinical reasoning are just as important for safety and quality as attention to minimum competencies attained through the nurse’s basic education, orientation, and continuing education.

Establishing a Healthy Work Environment

Research findings addressing the complexity of professional decision making regarding the clinical care and the management of work flow have suggested four important activities that can promote healthy work environments. These four activities include “designing out” system barriers to care, designing and implementing technology, focusing on the direct care function, and supporting the new RN. Benefits of addressing these activities to enhance the work environment along with examples of opportunities for improvement will be discussed.

“Designing Out” System Barriers to Care

Healthy work environments that support and foster excellence in patient care focus on designing processes to eliminate actual and potential system gaps that increase the complexity of RN work. Time spent on filling gaps or gathering resources distracts the nurse from clinically focused decision making. High reliability organizations focus on enhancing system reliability to increase safety and quality (Weick & Suttcliffe, 2007). Reducing the need for attention to unpredictable events or the management of flawed systems increases nurses’ capacity for mindfulness and sound clinical reasoning that will increase direct care safety and quality.

...the clinical environment should achieve a balance between privacy for patients and families and the clinical team’s capacity to visually scan and evaluate current workflow. Researchers have reported that teamwork is essential for best practice in clinical settings (IOM, 2001). The effectiveness and efficiency of teams depends on members of the team having up-to-date information and situational awareness about what is happening in the clinical situation (Endsley, 1995). To promote healthy work environments, the clinical environment should achieve a balance between privacy for patients and families and the clinical team’s capacity to visually scan and evaluate current workflow. Providers should be able to see at a glance the presence and location of other providers, patients, and family members, as well as notice patient travel patterns and the potential for any patient crisis or colleague needing assistance. Dashboards that are visible to everyone in a clinical area and reflect an accurate picture of patient needs facilitate continuous decision making about work priorities. Well-designed dashboards are those that reflect up-to-date information regarding team member availability and access, team assignments, and a patient’s status related to physical location, procedures ordered, procedures completed, results reported. Immediate and easy access to technology that facilitates communication with other team members also supports the continuous flow of the work of the nurses. Easy and simultaneous access to all patient information for all healthcare team members helps them to remain more aware of the unit work flow and be more alert to situations in which their help may be needed. Nurses move about their clinical areas from patient to patient, from patient to other members of the team, and from patient to supply and resource areas constantly scanning the environment for where they need to be next and how soon they might need to be there. This need for nurses to be continuously on the move for effective management of patient care must be considered when introducing any new system or technology. Barriers to effective care need to be “designed out’ before the system or technology is implemented.

Designing and Implementing Appropriate Technology

The addition of any new or redesigned technology should be developed from the beginning for the purpose of making nursing care easier and safer. Nurses already benefit from technology that supports patient care monitoring and documentation. Other technologies in support of a healthy work environment are also needed to assist nurses with their professional decision making in today’s complex environments. Technology that enhances the ability of professional nurses to remain mindful and increases their capacity to make sense of multiple, constantly changing, complex cues can facilitate their work-related efforts. Nurses need technology that provides quick access to all patient information at one time and in one place, organized in a way that enhances their recognition of clinical and patient-flow patterns. Technology should not require ‘hunting and gathering’ of this essential information.

Observations of nurses in the clinical setting reveal almost continuous movement by the nurse from one patient, or area of care or supplies, to the next (Ebright, Patterson, Chalko, & Render, 2003). This movement is often in response to unplanned requests or situations. Technology that travels with the RN (e.g., computerized tablets), and that contains up-to-date patient data (e.g., latest lab results, new orders) best fits with supporting the reality of RN work. Nurses consider various types of knowledge in providing care, such as patient schedules for test or therapies, expected time of return of patients from surgery, likelihood of receiving a new admission from the emergency room or admitting before the end of the shift, and expected arrival of other healthcare disciplines or providers. The availability of technology that provides as much up-to-date information as possible can facilitate the provision of direct care and guide the RN’s prioritization decisions.

The ‘right’ timing of a new technology can reduce the stress related to change and promote a healthy work environment. Technology support should be designed with an understanding of both the information required and the most helpful manner in which to present this information to the various disciplines that use the information. For example, an RN makes decisions about medication administration for a patient based on multiple factors, some of which include medication compatibility, vital signs, time of last dose, patient response, reliability of planned route, timing of patient procedures, medication availability, and time available to administer the medication before being needed elsewhere. Technology that is user friendly and supportive for accomplishing the work surrounding this complex activity would be that which presents up-to-date information regarding the above factors in a clear, concise, accessible format. Requiring the RN to access multiple technologies (e.g., multiple medication supply storage devices), or perform other complicated processes to confirm or clarify information (e.g., checking for new orders in one location before using medication bar coding at the bedside) is not supportive.

It is important to remember that today’s healthcare environments have limited capacity for accommodating increases in RN time spent on learning new activities. New approaches to assure RN learning and mastery before introduction of technology are essential. The ‘right’ timing of a new technology can reduce the stress related to change and promote a healthy work environment.

Focusing on the Direct Care Function

Nursing work has traditionally included filling system gaps (e.g., locating missing equipment and needed supplies, as well as secretarial and housekeeping activities) to maintain the resources needed to provide care. Yet activities related to achieving safe, quality care (e.g., duplicate documentation, additional documentation required by regulatory agencies, double checks, and learning changes in technology) have increased dramatically since the IOM report (IOM, 2000). Although RNs may have been able to handle many of these non-direct care activities in the past, patient acuity and speed of patient movement through our current healthcare system have escalated far beyond any concomitant increase in RN staffing that can accommodate the increase in patient safety initiatives.

Additionally, current increases in regulatory requirements call for certain types of documentation that are necessary but not relevant to the direct care of a given patient on the current shift. However, because RNs are physically present at the bedside and have access to medical records, they are often seen as the ideal person to enter and update the required information. This activity detracts from the RN’s ability to provide direct care. Organizational policies mandating that RNs complete this work, as well as performance audits conducted to monitor compliance, only add to the unhealthy stress associated with trade-off decisions when the RN is forced to choose between providing direct care or completing required documentation that contributes little to provision of safe care during a given shift.

A 2009 conference funded by the Agency for Healthcare Research and Quality (AHRQ) was held to initiate an understanding of the impact of multiple patient-safety initiatives on nursing work and subsequent patient safety and quality of care (Blegen, Donaldson, Seago, & Shapiro, 2009). The conference directors identified a need to examine the increasing numbers of safety initiatives that specifically target nursing direct care providers and, unfortunately, often involve additional work for these providers.

Our current patient acuity and complex work environment demands more than ever, that all available RNs focus primarily on clinical care rather than on activities that are unrelated to direct care needs. A healthy work environment calls for the elimination of as much non-direct care as possible from the work of RN care providers.

When non-professional nursing staff are the primary care givers at the bedside, rather than RNs, the RNs do not have the opportunity to make as many important observations and critical decisions necessary for safe care. Unlike previous redesigns of RN work, however, more deliberate focus and more research on the current complexity of direct care will be needed to redesign RN work in a way that maintains a healthy work environment. For example, it will be important to identify what direct care activities should be performed by the RN so as to enhance clinical reasoning and decision making on the part of the RN. In the 90s we redesigned the work of the RN in medical-surgical settings in a way that delegated to non-professional personnel many of the direct care (hands-on) activities that were not required by law to be done only by RNs. This redesign gave the RN responsibility for managing more patients but providing less direct care to the patients. What we did not realize in the 90s was that spreading the RN across more patients resulted in an enormous increase in decision making related to clinical care and workflow management. Nor did we appreciate how allowing the RN to spend more direct time with the patient and family in previous designs had provided the RN with the needed opportunity to assess the patient and identify the cues needed to make the best clinical decisions for the patient. RNs need to identify patterns of patient response so as to guide their decision making. They need to be able to observe the patients to accurately assess changes in areas such as patient’s movement, emotional response, non-verbal behavior, respiratory effort, and color, so as to make appropriate responses to the patient’s changing condition. These responses may include deciding whether to act quickly to prevent catastrophic deterioration in the first patient encountered, whether to care for the patient down the hall before helping this first patient, or whether to assist another care provider who needs assistance. When non-professional nursing staff are the primary care givers at the bedside, rather than RNs, the RNs do not have the opportunity to make as many important observations and critical decisions necessary for safe care.

Being supportive of the decision-making work of RNs would include scheduling RN-to-patient ratios in light of the limits of an RN’s capacity to keep track of information and make decisions. Research has indicated that there is a limit to the number of patients (and the amount of information about those patients) that one RN is able to manage effectively (Aiken et al., 2000). The research by Aiken et al. found that the RN-to-patient ratio influenced patient complications and mortality rates. Aiken and colleagues suggested that the work of RNs influences patient care outcomes, but the degree to which the RN can influence outcomes is limited by the number of patients assigned. Being supportive of the decision-making work of RNs would include maximizing quality RN time spent with patients and families to allow for adequate assessment to inform clinical reasoning and decision making for safe and quality care. Different care settings may differ in the amount of direct care time needed by the RN. It will be necessary to evaluate what is needed in each setting in order to provide safe and quality care.

A healthy work environment is one in which there is an appreciation both for the complexity of RN work and for the fact that there are limits to any RN’s ability to process critical information in the midst of work overload and unpredictable situations. This appreciation is demonstrated in a healthy work environment in which decisions about the design, timing, and implementation of new initiatives or system changes that affect direct care in any manner are made only with RN direct-care-provider participation and evaluation.

Supporting the New RN

The current predicted nursing shortage is easing, primarily because of a downturn in the economy. However, the faculty shortage will continue and worsen, decreasing the number of students admitted to nursing schools and subsequently the number of nursing graduates available to fill the RN positions that will be needed over the next decade (Buerhaus, Auerbach, & Staiger, 2009).

The ability of new graduates to make the complex decisions required for safe care in our current environments is not adequate for the complex, patient-care assignments they currently receive. Benner, Tanner, and Chesla (2009) have suggested that today’s workplace demands make the transition from being a competent nurse, who is able to pass the licensure exam, to being a proficient nurse, who is able to prioritize effectively, increasingly difficult. Healthy work environments in the future will be partly defined as those in which creative distribution of work enhances the learning of new graduates and the safe provision of care.

Dividing the number of patients by the number of RNs scheduled to provide direct care will not allow time for experienced RNs to support and teach the new graduate. New graduates who enter the nursing workforce will need support from those around them to build confidence in their decision-making abilities in the very complex situations they face. Retaining new graduates will require supportive work environments in which they can learn the important cognitive skills needed to deliver safe, quality care from experienced nurses. Additionally, Buerhaus, Auerbach, and Staiger (2009) noted that the increasing numbers of older adults with chronic diseases and co-morbidities will increase the need for patient surveillance. Patient surveillance (looking for early cues indicating patient deterioration) will require the ability of new RNs to notice and to make sense of even subtle cues indicating the need for action in complicated care situations and the need for early rescue of patients in life-threatening situations.

Orientation designs for new RN graduates should focus on strengthening these critical skills through mentoring by experienced RNs who have the time for detailed discussions (story-telling) explaining the rationale for their recommended decisions. These supportive efforts may decrease the stress and demoralization that new graduates experience when they begin their nursing careers in today’s complex, fast-paced environments. New models of work distribution and patient assignments are needed that will free experienced RNs to provide the support described above. We need direct-care RNs to think outside of the traditional ways of assigning the work of caring for a group of patients to the staff available. Dividing the number of patients by the number of RNs scheduled to provide direct care will not allow time for experienced RNs to support and teach the new graduate. Experienced RNs who make daily assignments are encouraged to think through the following questions:

  • What distribution of care delivery, or alternative assignment of RNs, would assure that every patient was assessed by an experienced RN every shift?
  • What distribution of care delivery, or alternative assignment of RNs, would assure that all new graduate nurses would receive mentoring for their assigned patient care and work management responsibilities from an experienced RN every shift?

Merely telling the new graduate to seek help if needed is not sufficient, given that new graduates may not pick up on subtle cues that signal patient deterioration and/or work management failure. Thinking through the answers to these questions can facilitate creativity in finding new ways to make daily assignments that enhance the learning of new graduates, thus improving the safety and quality of the care provided.

Formalized, easily accessible processes that encourage new graduates to seek out willing, enthusiastic, experienced RNs for questions or guidance in critical situations are essential for patient safety as well as retention. Merely telling the new graduate to seek help if needed is not sufficient, given that new graduates may not pick up on subtle cues that signal patient deterioration and/or work management failure. In the past, new graduate progression was measured by number of patient beds, baths, and associated tasks they completed by a certain time of day or by the end of a shift. Given the trend toward more complexity in our healthcare environments, new graduate learning and performance must increasingly be measured by the level of clinical reasoning skill regarding patient care situations and by the choices made about workflow that support safe and quality care. Structures of support different from those that were adequate even five years ago are needed.


Cook, Render, and Woods (2000) proposed that the major barrier to making progress in safety and quality was the failure to appreciate the complexity of the work in healthcare today. Current research focusing on work complexity and related issues is enabling us to increase our understanding of RN decision making (the invisible, cognitive work of nursing) in actual care situations and grasp how both the knowledge and competencies of the RNs themselves, as well as the complex environments in which RNs provide care, contribute to patient safety, quality of care, and healthy work environments or lack thereof. A commitment to understanding and appreciating the complexity involved in RN work is needed to guide the more substantive and sustained improvements required to achieve safety and quality. Attention to, and action based on, an understanding of the complexity of RN work and the value of the four activities described above have the potential to achieve the goals of healthy work environments that include safe, quality care, desired patient outcomes, and nurse recruitment and retention.


Patricia R. Ebright, RN, DNS, CNS

Dr. Ebright is an Associate Professor in the Indiana University School of Nursing. Her healthcare experience includes 39 years as a registered nurse, with the first 28 years working as staff nurse, nurse manager, and clinical nurse specialist in acute care hospital settings. For the past nine years her research focus has been centered on healthcare-provider decision making in the context of actual care situations. This research is directed toward increasing understanding of the influence of work complexity on patient safety and quality of care, and on the implications for system design and nursing education. Dr. Ebright was a member of the first Patient Safety Leadership Fellowship class sponsored by the National Patient Safety Foundation. She serves on safety and quality groups for the state of Indiana as well as for local healthcare organizations.


Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job satisfaction. Journal of the American Medical Association, 288, 1987-1993.

American Association of Critical Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Executive Summary. Retrieved September 16, 2009 from American Association of Critical-/care Nurses website.

American Nurses Association. (2004). Nursing: Scope and standards of practice, American Nurses Association. Silver Springs, MD: American Nurses Association.

Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics. Second Edition, New York: Springer.

Blegen, M., Donaldson, N., Seago, J. A., & Shapiro, S. (2009). Conference report: Impact of patient safety initiatives on nursing workflow and productivity, Final Report, AHRQ conference Grant # R13-HS017672-01.

Buerhaus, P.I., Auerbach, D.I., & Staiger, D.O. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs-Web Exclusive. 28, no. 4 (2009): w657-w668. Retrieved September 22, 2009 from

Commission on Collegiate Nursing Education (CCNE). (n.d.), Standards for accreditation of baccalaureate and graduate degree nursing education programs. Retrieved September 17, 2009 from

Cook, R., Render, M., & Woods, D. (2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320; 791-794.

Cook, R., & Woods, D. (1994). Operating at the sharp end: The complexity of human error. In M.S. Bogner (Ed.), Human Error in Medicine. (255-310). Hillsdale, NJ: Lawrence Erlbaum Associates.

Ebright, P., Patterson, E., Chalko, B., & Render, M. (2003). Understanding the complexity of registered nurse work in acute care settings. Journal of Nursing Administration, 33(12), 630- 638.

Ebright, P., Patterson, E., & Saleem, J. (January, 2009). Nursing work: Impact of patient safety initiatives on nursing workflow and productivity. Presentation for AHRQ Funded Grant Workshop. San Diego, CA.

Ebright, P., Urden, L., Patterson, E., & Chalko, B. (2004). Themes surrounding novice nurse near-miss and adverse event situations. Journal of Nursing Administration, 34 (11), 531-538.

Endsley, M.R. (1995). Toward a theory of situation awareness in dynamic systems, Human Factors, 37, 32-64.

Institute of Medicine. (2000). To err is human: Building a safer health system. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. Washington D.C: National Academies Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press.

Kalisch, B. J. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.

Krichbaum, K., Diemart, C., Jacox, L., Jones, A., Koenig, P., Mueller, C. et al. (2007). Complexity compression: Nurses under fire. Nursing Forum, 42(2), 86-95.

Lindberg, C., & Lindberg, C. (2008). Nurses take note: A primer on complexity science. In C. Lindberg, S. Nash, C. Lindberg (Eds.), On the Edge: Nursing in the Age of Complexity. (pp. 23-47). Bordentown, NJ: PlexusPress.

Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: Nursing in the age of complexity. Bordentown, NJ: PlexusPress.

Patterson, E., Ebright, P., & Saleem, J. Investigating stacking: How do registered nurses prioritize their activities real-time? International Journal of Industrial Ergonomics, In review.

Potter, P., Wolf, L., Boxerman, S., Grayson, D., Sledge, J., Dungan, C., et al. (2005). Understanding the cognitive work of nursing in the acute care environment. Journal of Nursing Administration, 35(7/8), 327-335.

Tucker, A. L., & Spear, S. J. (2006). Operational failures and interruptions in hospital nursing. Health Services Research, 41(3 Pt 1), 643–662.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty. San Francisco: Jossey-Bass.

Wiggins, M.S. (2008). The challenge of change. In C. Lindberg, S. Nash, C. Lindberg (Eds.), On the Edge: Nursing in the Age of Complexity. (pp. 1-21). Bordentown, NJ: PlexusPress.

© 2010 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2010

Related Articles